A very basic cognitive formulation links a person's mood and behaviour to the way that he or she interprets or thinks about an event. Using this simple model we can understand that a person who believes that hearing voices is a sign of madness and impending incarceration is likely to feel anxious, and may hide away as a result. This would contrast with a person believing the experience of hearing voices means that he has special powers who may feel quite elated and may want to spread the word of his newly found gift.
Formulating can be done at different levels of complexity. A more detailed cognitive formulation examines why the person is interpreting events in a particular way. Following a cognitive model it is proposed that early experiences determine the manner in which the person sees himself in the world. These core beliefs then colour the person's view of events from there on, and such interpretations will influence the person's moods and behaviour.
Previously I had trained using Schneider's first rank symptoms of schizophrenia to "help me", and had spent my early years in nursing trying to reason why all the people I ever met who had been given a diagnosis of schizophrenia seemed to have so little in common. Formulation, as opposed to diagnosis, seemed just as baffling at first but did seem to offer more to my clients and to me. The experience of psychosis is overwhelming to both the client (Romme & Escher, 2000) and the therapist. The formulation provides an opportunity to understand and normalise psychotic experiences. I shared a client's formulation with her recently and she announced at the end of the session: "It's no wonder I'm like this".
Without a formulation the therapist can be likened to a General engaged in battle without planned tactics to guide him in the deployment of his troops and in the timing of his offensive. (Blackburn & Davidson, 1990).
This therapist had seemingly never timed "her offensive" before—hours were spent pouring over the inference of words. Was it that Janet believed she was special or was it that she believed she had not succeeded? As a true novice I was unable to generalise the approach I had been taught. That the formulation is actually a hypothesis did not reduce my desire to "get it right first time". I saw it as a static conclusive statement rather than a flexible starting point and was determined to gain an understanding of Janet's viewpoint and develop the formulation. This was not only to help me to make sense of her problems and guide my intervention but also to protect me from being overwhelmed by the labyrinthine constructs of her experiences.
Janet's childhood had been characterised by being "set apart". Her social position in the village was elevated by her parents' jobs. Her detached house overlooking the village was unique and her attendance at boarding school appeared to contribute to the development of two beliefs: that she was different and that academic achievement was important.
Janet was brought up in a family that placed great emphasis on academic and financial success. She enjoyed the school regime and had faith in the school motto "Work hard, pray hard, play hard". Her university years were characterised by a shifting of boundaries. She was living with other students without any routine and had struggled with an emotional relationship, feeling that it was "distracting her from her work". She was involved with an art group and involved in drama, living with artists in the early 1970s but then started to have difficulties with her studies, was unable to concentrate and was gripped with "intellectual paranoia". She must have felt confused and bemused as this was not her perceived destiny. Her family had "mapped out" that she should finish university and go into business with her sister. It was all planned. What was happening?
It appears that the stress surrounding these critical incidents may have contributed to her first episode, although Janet did not recognize how stressed she was. As a result of her emerging psychosis she was removed from university and returned home. Following her return she discovered that her family reacted differently to her. They appeared awkward in her presence and the comfortable, close relationship she had with her siblings now felt strained. Janet retreated to her bedroom on the very few occasions that they visited.
I wondered whether Janet's belief that she had an implant served two functions. It could be seen that by externalising blame for her perceived failures (i.e. it is the fault of the implant) Janet feels less personally responsible for her perceived inadequacy. How could she possibly have succeeded with an implant in her head? Secondly, her delusional beliefs appear congruent with her beliefs about the world and about herself, that she is different and special.
Her auditory hallucinations echoed her schema in that the voices she heard told her she was worthless. Sharing the entire formulation with Janet did not seem appropriate as it was at odds with her own explanation, and to have divulged this viewpoint might have jeopardised our relationship.
Formulation of Janet's problems
• Early experiences Elevated social position in home village Emphasis on academic success from parents
• Dysfunctional beliefs and assumptions I am different/special Emotions detract from achievement
Success is about academic and professional accomplishment Unless I am a complete success I am a failure
• Critical incidents
Perceived rejection by peers at university Struggling to keep up with work Distracted from academic work Fails exams
• Negative automatic thoughts
There is something wrong with me I have an implant controlling me "You are a waste of space" (voice) "You know nothing" (voice)
• Maintaining factors Isolation
Defensive function of delusion
Continued emphasis on academic achievement
• Physiological—Poor sleep/anxiety/unable to concentrate.
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